Anesthetic management for medialization laryngoplasty using concurrent infusions of dexmedetomidine, remifentanil, and propofol versus controls☆
Introduction
Medialization laryngoplasty (ML) is an operation for voice reconstruction performed for correction of unilateral vocal cord paralysis. The operative goal of ML is to move the edge of the paralyzed vocal fold closer to midline, which allows closure of the glottis during phonation. In some cases, a larger posterior glottal gap is present that requires arytenoid adduction (AA). ML is unique in that it requires intraoperative voice monitoring where the patient needs to phonate during the procedure [1]. Historically, ML was performed under local anesthesia, which was sometimes uncomfortable for the patient and technically difficult for the otolaryngologist due to coughing and laryngeal movement [2]. Sedation using a variety of monitored anesthetic care techniques can improve patient tolerance during ML [[1], [2], [3], [4], [5]], but a successful procedure requires the patient to maintain spontaneous breathing despite periods of deep sedation followed by periods of rapid emergence in order to phonate.
An anesthetic technique which uses a combination of dexmedetomidine, remifentanil, and propofol (DRP) for sedation has recently been described in a case series for ML [6]. This novel anesthetic combination offers several theoretical advantages owing to the pharmacology and clinical effects of these agents. Dexmedetomidine is a central alpha-2 agonist with anxiolytic, analgesic, and sedative effects which mimic normal sleep cycles. Importantly, dexmedetomidine is not known to induce respiratory depression [7,8]. Remifentanil is a potent ultra-short acting synthetic opioid with a blood brain equilibrium half-life of 12 min and a context-sensitive halftime of 3 to 8 min, thus is easily titratable. It is eliminated rapidly by nonspecific esterases; therefore, there is no accumulation in the setting of renal or hepatic dysfunction. Propofol is a gamma-aminobutyric acid agonist and is one of the most widely used anesthetic agents for sedation and general anesthesia and is generally well tolerated at low doses [9]. It does not have analgesic properties. Propofol is rapidly metabolized to inactive metabolites and can be used without extensive dosing changes in patients with hepatic and renal failure, unlike many other sedation agents [9,10]. Using DRP together has potential advantages, including antiemetic effects, short acting titratable analgesia, improved pharyngeal muscle relaxation, and the ability to deeply sedate the patient while allowing for rapid titration to an awake state for phonation owing to the drugs' short half-lives.
Successful anesthetic management using combinations of these medications have been described for other procedures. For cystoscopy, co-administration of dexmedetomidine and remifentanil has been reported to result in optimization of analgesia, onset of appropriate level of sedation, speed of emergence and surgeon satisfaction [8]. Arpaci et al. compared the co-administration of dexmedetomidine/remifentanil to midazolam/remifentanil and found that the dexmedetomidine/remifentanil combination produced faster onset of targeted level of sedation, faster recovery times, and less postoperative cognitive dysfunction [7]. Kim et al. assessed the efficacy of dexmedetomidine/remifentanil compared to propofol/remifentanil in patients undergoing endoscopic submucosal dissection and found that propofol produced a more profound decrease in pharyngeal muscle tone and pharyngeal reflex compared to dexmedetomidine [10].
Our practice has developed a protocol using DRP sedation which has been accepted for publication as a case series of 75 patients [6]. To support this practice change, we performed a retrospective case controlled study to assess if DRP is associated with improvements in procedural time or reduction in the use of other sedating medications. Our hypothesis is that this technique is superior for ML ± AA compared to our traditional anesthetic management.
Section snippets
Methods
This study was approved by the Mayo Clinic, Rochester MN, Institutional Review Board (protocol number 16-002294, approved on 4/18/2016, handled by Ellen Olson). Consistent with Minnesota Statute 144.295, all patients in this study provided prior authorization for research use of their medical records.
Results
During the study time frame, 58 cases of patients who underwent ML ± AA utilizing DRP were identified. These patients were matched with 116 control patients who underwent ML with traditional anesthetic management. Patient characteristics are presented in Table 1. Table 2 compares the administration of different anesthetic agents between cases and controls. There was a reduction in the use of other sedating medications with DRP.
DRP was associated with a decrease in anesthetic and surgical time
Discussion
The main finding in this study is that a novel DRP anesthetic for sedation with ML procedures was associated with a meaningful reduction in anesthetic and surgical durations. In addition, the DRP anesthetic allowed less additional sedating medications (fentanyl and midazolam) to be administered in the perioperative period. Subjectively, it was the perception of the surgical team that DRP sedation provided superior titratability and assessment of phonation with improved surgeon and patient
Conclusions
The novel monitored anesthetic care technique using a combination of dexmedetomidine, remifentanil, and propofol for outpatient ML ± AA was associated with decreased surgical and anesthetic durations and a statistically significant reduction of supplemental midazolam and fentanyl use. However, increased rates of hypopnea associated with DRP need to be recognized and the perioperative team must be prepared to manage this complication if using this technique.
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The authors have no competing interests to disclose.